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Hagen etal. exclusively evaluated the use of intraluminal ICG to perform a leak test after robotic-assisted RYGB [31]. In this study, patients underwent a series of GJ anastomotic leak tests. Patients rst underwent an air insufation test, followed by a methylene blue leak test, and then an ICG leak test. No leaks were detected using air insufation or methylene blue; however, there were four positive ICG leak tests. The leak was repaired intraop­eratively and without complications. The authors concluded the intraluminal ICG was a more sensitive leak test than air insufa­tion or colored dye [31]. Utilization of intraluminal ICG as a leak test after RYGB appears promising and warrants further investi­gation.

6.5% in the absence of pharmacologic therapy. After 2years of follow-up, 95% of patients who received a BPD achieved remis­sion of diabetes, compared to 75% in the RYGB group, and 0% in the conventional medical therapy group (p<0.001) [51]. The dis­tal delivery of food instigates a complex interaction of incretins, bile acids, and the microbiome that contribute to the remarkable metabolic impact of the BPD/DS compared to other bariatric sur­geries [53–55].

eostomy, and construction of an ileoileostomy to connect the bil­iopancreatic limb and common channel. The rst step includes measuring the small bowel. Starting from the terminal ileum, the bowel is marked at the site of the ileoileostomy (100 cm to 150cm) and then again at the site of the future duodenoileostomy (200cm to 300cm). The next step is to perform the SG as previ­ously described. Some surgeons opt to create a larger gastric res­ervoir over a bigger calibration tube, for example, a 50 French bougie. After performing a cholecystectomy, the peri-duodenal dissection is begun 3cm to 5cm distal to the pylorus. The gastro­duodenal artery is identied, and a retro-duodenal tunnel is cre­ated above the artery. The duodenum is transected near the junction of the rst and second portions of the duodenum. The duodenoileostomy is fashioned between the proximal duodenal stump and the previously marked ileum. The duodenoileostomy can be created via a handsewn or stapled technique. Next, the ileum is transected proximal to the duodenoileostomy, and a leak test is performed. The ileoileostomy is created between the previ­ously marked distal ileum and the newly created biliopancreatic limb. Both unidirectional and bidirectional techniques have been described. The mesenteric defects at the ileoileostomy and trans­verse colon are closed with permanent suture. The results are a 100cm to 150cm alimentary limb and a 100cm to 150cm com­mon channel for a combined 200cm to 300cm total limb length and an extremely long biliopancreatic limb. To perform the SADIS/SIPS, a loop duodenoileostomy is constructed around 300cm from the terminal ileum.

2.5mg/mL ICG solution (2.5mg of ICG) is then given intrave­nously after transection of the duodenum, followed by a 10mL saline ush. The transected duodenum is evaluated under near­infrared light to evaluate perfusion. A bright or dull uorescence hue is interrupted as sufcient perfusion to continue with the next steps in the BPD/DS procedure. The absence of uorescence is considered restricted perfusion. An extended time to reevaluate the perfusion or resection of the duodenum is performed based on surgeon judgment.

There are a few pitfalls to consider when incorporating ICG angi­ography into the BPD/DS or SADIS/SIPS procedures. At times, due to the extended dissection, the duodenal stump may appear dusky and the ICG angiogram will show diminished perfusion. The options are to the resect this portion of the duodenum or cre­ate an anastomosis to the dusky tissue. Resection is complicated by the location of the pylorus and possibility of needing to convert to a gastroileal anastomosis or RYGB.In our experience, despite an ICG perfusion test with diminished blood ow, continuing with the duodenoileal anastomosis is a reasonable option. The duodenum has a concentrated submucosal vasculature that leads

Although it is not reported, intraluminal ICG has been used to evaluate for a leak at the duodenoileostomy in our practice. Like previously mentioned, a solution is created with 12.5mg of ICG dissolved in 100mL of sterile 0.9% normal saline. The premixed solution is then instilled through the orogastric tube by the anes­thesiology team. The duodenoileal anastomosis is inspected with the near-infrared laser of the camera enabled. Patency of the anastomosis is conrmed when the ICG is observed shining through the wall of the duodenal bulb and across the anastomo­sis into the lumen of small bowel (Video 7.5). The anterior and posterior sides of the anastomosis are evaluated for intraperito­neal leakage of uorescence. The sharp contrast of ICG and the background tissue is especially obvious under the near-infrared light. A positive leak occurs when bright green uorescence is located outside of the lumen within the peritoneal cavity. The area of concern is oversewn, and a second leak test is performed. If the second leak test is positive, the surgeon must decide on another attempt at repair versus resecting and recreating the anastomosis.

The number of primary bariatric procedures continues to grow as does the number of revisional bariatric procedures [70]. Revisional bariatric surgery is associated with increased morbidity and mor­tality compared to primary bariatric surgery, with an overall com-

plication rate as high as 10% to 50% [71]. The rate of anastomotic leak is also signicantly higher in revisional cases [70, 71]. In a 13-year study at a tertiary care referral center, the incidence of anastomotic leak after revisional surgery was 13% [71].

Complications after SG to RYGB include GJ anastomotic dehiscence, remnant staple line leaks, and surgical site infections (including organ space, deep, and supercial). Notably, in a single- institution study of SG to RYGB cases, the incidence of anastomotic leak at the GJ was 3.4% [13]. ICG may help reduce the complication rate during a conversion of SG to RYGB.For example, ICG is administered intravenously to help identify the blood supply of the sleeve stomach, particularly the left gastric artery. The left gastric artery is an important landmark to identify during the creation of a gastric pouch from a sleeve stomach, as it is the main blood supply to the future gastric pouch. Once identi­ed, the gastric pouch is created by cutting across the sleeve below the level of the left gastric artery. Indocyanine green can also be injected to highlight the biliary system and edge of the liver during revisional bariatric surgery (Video 7.6). In the situa­tion where the sleeve is dilated or a large redundant fundus is identied, the sleeve may require tailoring vertically to the angle of His to make an appropriate gastric pouch. This situation leaves